RevBrasAnestesiol.2014;64(5):369---372
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Anesthesia
for
cesarean
section
in
pregnant
woman
with
Guillain
Barré
syndrome:
a
case
report
Thiago
Nobre
Queiroz
a,∗,
Flora
Margarida
Barra
Bisinotto
b,
Thaisa
Mara
da
Mota
Silva
c,
Laura
Bisinotto
Martins
daProgramadeResidênciaMédicaemAnestesiologia,HospitaldasClínicas,UniversidadeFederaldoTriânguloMineiro,
Uberaba,MG,Brazil
bUniversidadeFederaldoTriânguloMineiro,Uberaba,MG,Brazil
cProgramadeResidênciaMédicaemOftalmologia,HospitaldasClínicasdaUniversidadeFederaldeUberlândia,Uberlândia,
MG,Brazil
dUniversidadedeRibeirãoPreto,RibeirãoPreto,SP,Brazil
Received11July2012;accepted28February2013 Availableonline12February2014
KEYWORDS
Generalanesthesia; Pregnancy;
Diseases; Neuromuscular relaxant; GuillainBarré
Abstract
Backgroundandobjectives: GuillainBarrésyndrome(GBS)isanautoimmuneneurological dis-easecharacterizedbyanacuteorsubacutedemyelinatingpolyradiculoneuritis.Itisanunusual event during pregnancy and achallenge for the anesthesiologist, due to the possibility of impairmentofneuromuscularfunctionandoccurrenceofrespiratorycomplicationsinthe post-operative period.The objectiveofthispaperistodiscussthe anestheticmanagementofa pregnantpatientaffectedbythedisease.
Casereport: Femalepatient,30yearsold,38weeks’pregnant,diagnosedwithfetaldeaththat occurredaboutaday,andwithSGB.Cesareansectionwasperformedundergeneralanesthesia, progressingwithoutcomplicationsperioperatively.
Conclusions: Althoughitisuncommon,GBScanaffectpregnantwomenandthe anesthesiolo-gistmayencountersuchpatientsinhis(her)dailypractice.Itisimportanttounderstandthe peculiaritiesofGBStoadequatelyaddressthepatientintheperioperativeperiod,contributing toitsbetterevolution.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
Anestesiageral; Gestac¸ão; Doenc¸as;
AnestesiaparacesarianaemgestantecomsíndromedeGuillainBarré:relatodecaso
Resumo
Justificativaeobjetivos: A síndrome de Guillain Barré (SGB) é uma doenc¸a neurológica autoimunequesecaracterizaporumapolirradiculoneuritedesmielinizanteagudaousubaguda.
∗Correspondingauthor.
E-mail:thnobre@hotmail.com(T.N.Queiroz).
370 T.N.Queirozetal.
Relaxante neuromuscular; GuillainBarré
É um eventoincomum duranteagravidez e um desafiopara oanestesiologistapela possi-bilidadede comprometimentodafunc¸ão neuromuscular edecomplicac¸ões respiratóriasno pós-operatório.Oobjetivodestetrabalhoédiscutiromanejoanestésicodapacientegestante afetadapeladoenc¸a.
Relatodecaso:Pacientedosexofemininocom30anos,gestantede38semanas,com diagnós-ticodeóbitofetalhaviaumdiaeSGB.Foisubmetidaàcesarianasobanestesiageral,evoluindo semintercorrênciasnoperioperatório.
Conclusões:Apesardeserincomum,aSGBpodeacometergestanteseoanestesiologistapode sedepararcomessetipodepacientenasuapráticadiária.Éimportantecompreenderas pecu-liaridadesdaSGBparaseabordaradequadamenteapacientenoperioperatório,contribuindo paraasuamelhorevoluc¸ão.
©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Patientswithpreexistingneurologicaldiseasesrepresenta challenge for the anesthesiologist, withrespect to spinal blocks. Historically a more conservative approach is not touse the neuraxial blockade in these patients, because thispracticecouldworsentheneurologicalcondition.1The
presenceofacurrentpregnancymakesthisaevengreater challenge,becauseofconcernaboutfetalwell-being.
AnesthesiaforpatientswithGBSisanuncommonevent in anesthetic practice,still with some controversy in the literature.The objectiveof this reportis to describethe anestheticmanagementofapregnantpatientwithdiagnosis of GBS who underwent a cesarean section. The anes-theticimplicationsofSGBandthenecessaryconsiderations when choosing a particular anesthetic technique will be approached.
Case
report
Female patient,30 yearsold, 83kg, 170cm tall, with38 weeksofgestation,diagnosedwithfetaldeathaboutaday and with Guillain Barré syndrome (GBS). She was admit-tedfor emergencycesarean sectionfor obstetricreasons. The patient reported acute flaccid tetraparesis picture that started 20 daysago, withworsening in the lastfour days. The beginning of tetraparesis was symmetrical in thelowerlimbs,progressing latertotheupperlimbs.She reportedparesthesiaof allfourlimbs,without sphincteric changes.
The previous history related anemia and urinary tract infection during the current pregnancy. Laboratory tests werenotavailableandobstetricultrasonographyreported malformationandfetaldeath.Thepatientwasadmittedto theoperatingroomwithahemodynamicallystablepicture, eupneicandwitheight-hour-fast.Onphysicalexamination, flaccidtetraparesis,areflexiawithdistalpredominance of lowerlimbs and absence of sensorylevel were observed. The monitorization consisted of cardioscope in DII and V5, pulse oximetry, noninvasive blood pressure, capnog-raphy and monitoring of neuromuscular transmission by acceleromiography (TOF Watch SX®) of adductor pollicis, withstimulationoftheulnarnervebythetrainoffour(TOF) stimulationseveryfifteenseconds.
The initial blood pressure was 115×75mmHg, sinus rhythm witha heart rate=100bpmand pulseoxygen sat-uration=96%. Venoclysis was done with 18G catheter, continuing with the administration of metoclopramide 10mg and ranitidine 50mg 30min before induction of anesthesia. After administration of 100% oxygen for three minutes via face mask, midazolam (3mg) was administered and a continuous infusion of remifentanil (0.5gkg−1min−1) was initiated during three minutes, followed by lidocaine (80mg), etomidate (20mg) and rocuronium(80mg).
Inrapidsequence,trachealintubationwasuneventfully performed.Anesthesiawasmaintainedwith2%sevoflurane andremifentanilbycontinuousinfusion(0.2gkg−1min−1). The procedure lasted two hours. At that moment T2 in TOFwasnoted;neostigmine(3.0mg)andatropine(1.5mg) wereadministered.After30min,thepatientwaswithgood breathingpattern,T4/T1ratio>90%,andwithcooperative demeanor. The tracheal extubation was uneventful. The patient was taken to the post-anesthetic recovery room, wheresheremainedundercontinuousmonitoring.Thenext day, the patient was transferred to the intensive care unit.
Discussion
Inourcase,generalanesthesiawaschosen forperforming thecesareansectioninapatientwithGBS.Asthefetuswas notviableandthepatientwasinfastingformorethaneight hours,general anesthesia wasconsidered more beneficial
versusspinalblock.
Historically, it is considered prudent to avoid regional anesthesia in patients with preexisting neurological dis-eases.Thisconductisbasedonthefactthatthesediseases mayworsen;oranewdeficitmaydevelopperioperatively.1
What istheimportanceofthe existenceof aneurological diseaseandofneuraxialanesthesia?Thepresenceofa pre-existingclinicalorsubclinicalneurologicalimpairmentmay increasetheriskfornewlesionsorworsentheexistingones duringtheperioperativeperiod.
This syndrome, known as double-crush,2 was first
AnesthesiaforcesareansectioninpregnantwomanwithGuillainBarrésyndrome 371
disease would be considered as the first risk factor (first crush)andotheraggression(secondcrush)wouldberelated toanesthesia, duetomechanical traumabytheneedleor catheter,ischemiacausedbythevasoconstrictoragent,or chemicalinjury(neurotoxicity)producedbythelocal anes-theticitself.
Bothdiseasesofthecentralnervoussystem,likemultiple sclerosis and others, as well as diseases of the periph-eralnervoussystem(hereditaryornot),aresusceptibleto complicationsafterregionalanesthesia.GBSisanacquired autoimmune peripheral neuropathy, characterized by an acuteorsubacutedemyelinating polyradiculoneuritis.GBS primarilyaffectsperipheralnerves,buttheproximalnerve rootsandcranialnervesmayalsobecompromised.Its eti-ologyremainsunknown.
Usually,GBSisprecededbyinfection,especiallyofupper respiratory pathways and gastrointestinal tract. Probably themechanisminvolvedisthatofmolecularmimicry. How-ever,insomecasesthisassociationbetweenpriorinfection andGBSisnotevidentorevenreported.This syndromeis mainly characterized by a progressiveascending paralysis withareflexiaandalbuminocytologicdissociationon exam-ination ofcerebrospinal fluid.Weaknessmay bemild, for instancedifficultywalking,orsevere,suchasquadriplegia andcompleterespiratoryfailure.3---5
GBS complicating pregnancy is a rare and of high-risk event. The annual incidence of GBS in the general popu-lationis0.75---2casesper100,000inhabitants.6Menare1.5
timesmoreaffectedthanwomen.3Theincidenceincreases
with age3 and appears to be lower in pregnant women,
in whomthe disease arises primarily in thethree months afterchildbirth.7Theendofpregnancydoesnotaccelerate
therecovery of thepatient; rather,aworseningof symp-toms occursafter delivery (both vaginal andsurgical).7 A
favorableoutcomeinmostcasesisobserved,withneonatal survival rateof 95.7%.8 Despitethe patient’s neurological
commitment,uterinecontractionsandcervicaldilationare maintained,whichmakespossiblethevaginaldelivery.8
Oneshouldalwayskeepinmindthepossibilityof auto-nomicdysfunctionandoflowermotorneuronlesion when doinganesthesiainapatientaffectedbyGBS.Theprofound hypotensionin responseto simple position change, blood loss or positive airway pressure reflects the commitment of cardiovascular compensatory responses.9,10 Moreover,
nociceptive stimuli, such as laryngoscopy, can trigger an exaggerated increase insystemic blood pressure.Because ofthisunpredictablebehavior,itwouldbewisea continu-ousmonitoringofsystemicbloodpressurewithintra-arterial catheter, especially in cases of surgical procedures more complexorthatinvolvemajorbloodloss.9,10
In this case, the option for anesthesia was based on reports of worseningof clinical picture after spinal anes-thesia,andthenatureofthecase:apregnancywithadead fetus.Generalanesthesiawasinducedwithrapidsequence technique,because ofthe risk ofbronchoaspiration, both bySGBandbypregnancy.TheuseofsuccinylcholineinSGB iscontraindicated,duetotheriskofsevereandpotentially fatalhyperkalemia.9---13
There is an increase (upregulation) of extrajunctional musclenicotinicreceptorsofacetylcholine11,14 that,when
depolarizationoccursbytheactionofsuccinylcholine,lead toalargeeffluxofintracellularpotassiumtotheplasma.It
isprudentnottousesuccinylcholineafter48---72hofonset ofSGBpicture,12anditsuseshouldbeavoidedinpatients
witharecenthistoryofthesyndrome,becausethereturnto normalcymaytakeweekstoyearsaftertheinitialcausehas ceased.12Whennecessary,nondepolarizingmusclerelaxants
canbe used10 and a carefulmonitoring of neuromuscular
blockadeshouldbeinstituted.
Ideally, before surgical procedures, patients should be investigated for pulmonary function,7 because although
asymptomatic,theymaypresentsignificantimpairmentof lungfunction,which maybeexacerbatedpostoperatively, andventilatorysupportmustalwaysbeavailable.9,10
Thereisnodiscussion,inpatientsundergoingCesarean section, as to the benefits of spinal block, which is the technique of choice. General anesthesia is associ-ated with increased maternal mortality, mainly due to failures in tracheal intubation, difficulty to ventilate and oxygenate and pulmonary aspiration of gastric contents. In SGB, the regional anesthesia can provide benefits, because of the great autonomic lability present.15
How-ever, there are reports of development of the syndrome and neurological worsening of symptoms after epidural anesthesia.7---9,16,17
GiventhattheSGBmayhaveaggravateditscourseduring theperioperative period,8,16 itbecomesdifficult toassess
theseassociations. There are alsoseveral cases of favor-able outcomes after regional anesthesia8,18---20 and there
is no evidence that regional anesthesia can trigger the disease.16Therefore,GBSshouldnotbeconsideredan
abso-lutecontraindicationtoneuraxialanesthesia.8,9,18 Thereis
an increased sensitivity tolocal anesthetics, so the dose should be reduced and, wherever possible, fractionated, aimingtoavoidlengthyblocks.15
General anesthesia, despite all caveats, is safe in patientswith SGB9 and shouldbe preferredin cases with
respiratoryinvolvement.15Preferenceisgiventoanesthetics
withfastmetabolismandwithlittlehemodynamic repercus-sion.
Inthiscase,ifthefetuswasviable,regionalanesthesia wouldbeamorelogicalchoiceandthebenefitswould out-weightherisks.8Theoptionbygeneralanesthesiaprevented
theinvasionofneuraxis, andfetalunfeasibility minimized thepotentialrisksofthetechnique.
We conclude that, whatever the anesthetic technique chosenbytheanesthesiologist,itshouldbediscussedwith the surgical team, the patient and her relatives,8,16,18,19
to explain the risks associated with each type of procedure.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Jacob AK, Kopp SL. Regional anesthesia in the patient with preexisting neurologic disorders. Adv Anesth. 2011;29: 1---18.
372 T.N.Queirozetal.
3.Hughes RAC,Cornblath DR.Guillain-Barrésyndrome.Lancet. 2005;366:1653---66.
4.RichardsKJC,CohenAT.Guillain-Barrésyndrome.BrJAnaesth. 2003;3:46---9.
5.Vedanarayanan VV, Chaudhry V. Guillain Barré syndrome ---recentadvances.IndianJPediatr.2000;67:635---46.
6.Ropper AH. The Guillain-Barré syndrome. N Engl J Med. 1992;326:1130---6.
7.ChestnutDH,PolleyLS,TsenLC,etal.Chestnut’sobstetric anes-thesia:principlesandpractice.4thed.Philadelphia:Elsevier; 2009.p.1066.
8.ChanLYS,TsuiMHY,LeungTN.Guillain-Barrésyndromein preg-nancy.ActaObstetGynecolScand.2004;83:319---25.
9.Miller RD, Eriksson LI, Fleisher LA, et al. Miller’s anesthe-sia,vol.1,7thed.Philadelphia:ChurchillLivingstone;2009. p.1173.
10.HinesRL,MarschallKE.Stoelting’sanesthesiaandco-existing disease. 6th ed. Philadelphia: Elsevier Saunders; 2012. p. 269---70.
11.TripathiSS,HunterJM.Neuromuscularblockingdrugsinthe crit-icallyill.ContinEducAnaesthCritCarePain.2006;6:119---23. 12.Martyn JAJ, Richtsfeld M. Succinylcholine-induced
hyper-kalemia in acquired pathologic states. Anesthesiology. 2006;104:158---69.
13.FeldmanJM.Cardiacarrestaftersuccinylcholineadministration inapregnantpatientrecoveredfromGuillain-Barrésyndrome. Anesthesiology.1990;72:942---4.
14.NaguibM,FloodP,McArdleJJ,etal.Advancesinneurobiology oftheneuromuscularjunction:implicationsforthe anesthesi-ologist.Anesthesiology.2002;96:202---31.
15.GriffithsS,DurbridgeJA.Anaestheticimplicationsof neurolog-icaldiseaseinpregnancy.ContinEducAnaesthCritCarePain. 2011;11:157---61.
16.Kocabas S, Karaman S, Firat V, et al. Anesthetic manage-mentofGuillain-Barrésyndromeinpregnancy.JClinAnesth. 2007;19:299---302.
17.WiertlewskiS,MagotA,DrapierS,etal.Worseningofneurologic symptomsafterepiduralanesthesiaforlaborinaGuillain-Barré patient.AnesthAnalg.2004;98:825---7.
18.BrooksH, ChristianAS,MayAE.Pregnancy, anaesthesia,and GuillainBarrésyndrome.Anaesthesia.2000;55:894---8. 19.VassilievDV, Nystrom EUM, Leicht CH. Combined spinal and
epidural anesthesia for labor and cesarean delivery in a patientwith Guillain-Barresyndrome. Reg Anesth Pain Med. 2001;26:174---6.
